The independent inquiry into the murder of 21-year-old Gary Douch in Mountjoy Prison, Dublin, will likely expose severe shortcomings in the handling of at-risk, dangerous and mentally ill inmates across the prison service.
The fact that an inmate has been murdered in a protection cell by another prisoner with a history of mental illness raises a wide range of serious questions about the preparedness of the prison service to cater for those in its care.
Three separate inquiries into the prison murder are now under way. These are being conducted by gardaí, prison staff and former senior civil servant Michael Mellett. He has been appointed by the Minister for Justice, Michael McDowell, to carry out the independent inquiry.
He has served as a member of the Council of Europe Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) and is a former deputy secretary in the Department of Justice.
While the investigations are just beginning, the facts that had emerged by last night indicated serious system failures.
On Monday night Gary Douch told prison staff that he feared for his safety on the C1 landing.
When asked whom he feared and why, he failed to disclose any further details. Such non-co-operation is common among prisoners who, always mindful of retribution, rarely disclose anything incriminating about other inmates.
Mr Douch was taken to the basement area where he was housed in a protection cell overnight. These cells have no beds and were not designed to house inmates overnight.
However, because of overcrowding, they are used as protection cells. Inmates take mattresses from a storage room to sleep on at night and store them away again in the morning.
Before the cell door was locked for the night Mr Douch was asked if he had any difficulty sharing with the six other men that were to be housed in the same cell. He indicated he was satisfied with the arrangements. The door was then locked for the night.
Prison sources have told The Irish Times that it would be usual for the officers on duty to check on the inmates every 15 minutes during the night by looking through a glass panel on the cell door. The inquiries now under way will want to determine if this procedure was followed.
Prison officers unlocked the cell at around 6.30am. The other inmates emerged from the cell and after a short time staff realised that one inmate was missing. They found the dead man lying among the mattresses.
At least some of the other inmates in the cell have told prison staff that a 23-year-old Dubliner housed with them overnight was the killer. They have told of a sustained attack.
It remains unclear why the others did not bang on the cell door when the attack began. The motive for the attack is also unclear but the suspect is a violent man with psychiatric problems.
He had spent time in a number of jails in recent times. He had also recently been assessed at the Central Mental Hospital before being returned to Cloverhill last week. He had been transferred to Mountjoy on Sunday.
The results of this psychiatric assessment and the reasons why he was sent back to prison will be of vital interest to the inquiry by Mr Mellett. However, prison sources said such a practice happens regularly.
The apparent failure, or inability, of the prison service to act on a range of recent expert observations relating to issues of overcrowding and mentally ill inmates will also be examined closely.
A report commissioned by the Probation and Welfare Service last year identified very high numbers of mentally ill people ending up in prison.
The report found of the 25 per cent of the 3,200 prison population who were homeless on committal, one in three had been previously diagnosed with a mental illness and two in three had spent time in a psychiatric hospital.
The visiting committee at Arbour Hill Prison last year expressed grave concerns at the practice of mentally ill prisoners being taken to the Central Mental Hospital for short periods only to be returned to prison.
Two prisoners treated in this manner took their own lives at the jail in 2004 while a third attempted suicide. The committee said "the absence of a dedicated psychiatrist remains a cause for concern". This was "pertinent to the 'suicide issue'" referred to in the report.
The inspector of prisons, Judge Dermot Kinlen, has raised serious concerns at the closure of rehabilitative services in some prisons, such as workshops.
